Combined percutaneous balloonvalvuloplasty of mitral and tricuspid valves

Combined mitral and t r icuspid stenosis are rarely encountered in pat ients with rheumat ic hear t disease. 1 In spite of being a recently introduced technique, balloon valvuloplasty in noncalcified mitral stenosis has been found to be consistently effective in the t rea tment of this condition. 2 Successful double balloon valvuloplasty in t r icuspid stenosis 3, 4 has recently been reported. We repor t a case in which balloon valvuloplasty was performed on both the mitral and tr icuspid valves during the same procedure, with good immediate and midte rm results, A 48-year-old woman pat ien t with New York Hear t Association (NYHA) functional class I I I was admi t t ed to the hospital for the evaluation of rheumatic mitral and tr icuspid stenosis. Physical examinat ion showed a typical mitral facies with p inkish-purple patches on the cheeks, elevated jugular venous pressure, and mild hepatomegaly. A loud first hear t sound and an opening snap were heard at the apex, with a low-pitched diastolic murmur. There was also a diastolic rumble along the lower left sternal border combined with a systolic murmur , both increasing on inspiration. The electrocardiogram (ECG) showed atr ial fibrillat ion and right-axis deviation. The chest x-ray film showed left and right atr ial enlargement with increased upper lobe vascular markings and enlargement of the pulmonary arteries. Echo-Doppler technique showed pure mi t ra l stenosis. The valve was flexible, with no evidence of calcification. Mit ra t valve area, calculated from the mitral flow using the pressure halft ime method as described by Hatle et al., 5 was 1 cm 2. Direct p lanimetry of the mitral orifice gave a valve area of 1.1 cm. 2 The left a t r ium was moderately enlarged and the left ventricle was normal. The tr icuspid valve showed a combinat ion of stenosis and mild incompetence. Tricuspid pressure halft ime was 366 msec. In the light of these findings, we decided to a t t empt percutaneous balloon valvuloplasty on both valves if the assessment was corroborated by diagnostic catheterization. Wri t ten consent was obtained from the pat ient . The catheterizat ion included the measurement of the mitral valve gradient, cardiac outpu t ( thermodilution), and calculation of the area using Gorlin's formula. A left ventriculogram was performed in the right anterior oblique view. Simultaneous recordings of